Dan Diamond, Managing Editor
Today's California Healthline features my look back at the Golden State's ambitious efforts to implement the health reform law. State officials vowed in 2011 that they didn't want to settle for being "a pace car"; California needed to be the "lead car," one top official said at the time.
Did they succeed, and did it pay off? The column reviews three of California's strategies and whether the state gained anything by speeding to implement the ACA. (This report from Health Access, a California-based advocacy organization, also is a great review of the state's ACA-related legislation and the associated benefits.)
Why one governor decided to support the 'imperfect' ACA
The California Healthline column includes interviews with many key players, but one figure is missing: Gov. Arnold Schwarzenegger.
Schwarzenegger had dreamed of enacting universal health care in California, launching a major push in 2007 to expand health coverage through a system that relied on mandates and insurance exchanges. But by 2008, that effort had failed.
Two years later, California had another chance to participate in coverage expansion—President Obama's health expansion, to be specific. And the Affordable Care Act was "not perfect," according to Kim Belshe, who was California's secretary of HHS in 2010. It certainly wasn't the health reform that Schwarzenegger and his team originally envisioned. Many GOP leaders were pressuring their fellow Republican to wait before endorsing the law, too.
But as Belshe told me, "it was better for the people of California that we implement reform consistent with our priorities, our values." And about one month after the ACA was signed into law, Schwarzenegger threw his prominent support behind it.
How does the governor feel about national health reform, and his own role, a few years later? Since my Q&A with Schwarzenegger didn't happen in time for the final California Healthline story, I've pulled it out below.
- Where the states stand: Take a look at California and other states' decisions to opt into the ACA's Medicaid expansion.
Q: Your efforts to try and pass health reform in California helped tee up national debate, which ultimately led to the Affordable Care Act. How did your campaign to enact health reform in California prepare the state to implement the ACA, too?
Arnold Schwarzenegger: We spent a year consulting, debating, and negotiating with all the major stakeholders to drive toward some level of consensus around key issues like the individual mandate, subsidies for working families, and expanding the Medi-Cal program.
So much of the political infighting was behind us when the time came to implement health care reform.
California has had experience with exchanges and reform efforts so we had a deep reservoir of knowledge to draw from in designing the health care reform plan.
Q: You began implementing health reform in 2010, even as many other national leaders wavered or waited. Did the ACA’s legal or political challenges make you cautious, and if not, why not?
Schwarzenegger: Not at all. We knew there would be legal challenges with the [Employee Retirement Income Security Act] and sustaining an individual mandate, and we were confident the law would survive.
Q: More than three years later, California’s incredibly well-positioned on reform – the state’s health insurance exchange, for example, is arguably the most-prepared in the nation. In retrospect, what were the most crucial decisions that you made when implementing the ACA?
Schwarzenegger: Starting right away… not waiting to commit to implementing. Putting the leadership in place before I left office.
Q: Understanding that hindsight can be helpful, could California have moved quicker or differently when carrying out the law?
Schwarzenegger: No—California moved with great speed.
Governor [Jerry] Brown was rightfully cautious about committing state dollars to the expansion effort without some assurances from the federal Government. But that did not slow down implementation.
Q: When you think about your political legacy, where does health reform rank?
Schwarzenegger: I don't think about my legacy or time in office like that. I will leave that to the pundits.
I'm really proud of what we did on health care. Our initial push for health care reform in California set the stage for widespread health care reform and now California will lead the way [nationally].
I do know that [the U.S.] is a system in desperate need of reform and overhaul and am optimistic California is going to be a great case study.
One hospital leader on how he's implementing reform
Lloyd Dean, the CEO of California-based Dignity Health, discusses his top challenges when strategizing around ACA implementation, including the opportunities and pitfalls that accompany the insurance exchanges.
Read our interview with Lloyd.